Vertical Talus Congenital Convex Pes Valgus

The Deformity
irreducible dorsal dislocation of the navicular on the talus rigid flatfoot deformity

Etiology?

Pathoanatomy
Rockerbottom fixed hindfoot equinovalgus
due to contracture of the Achilles and peroneal tendons

rigid midfoot dorsiflexion

secondary to the dislocated navicular

forefoot aBducted and dorsiflexed

contractures of the EDL, EHL and Tibialis Anterior tendons

Clinical Presentation
rigid foot deformity talar head is prominent in medial plantar arch on exam
produces a convex plantar surface

patient may demonstrate a "peg-leg" or a calcaneal gait due to decreased push-off a careful neurologic exam needs to be performed
due to frequent association with neuromuscular disorders

Evaluation

Radiographs
Lateral
vertically positioned talus & dorsal dislocation of navicular
line in long axis of talus passes below the first metatarsal-cuneiform axis
before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation

forced plantar flexion lateral

shows persistent dorsal dislocation of the talonavicular joint
oblique talus reduces on this view

Meary's angle > 20 (between line of longitudinal axis of talus and longitudinal axis of 1st metatarsal)

forced dorsiflexion lateral

reveals fixed equinus

Radiographic Evaluation
AP
valgus of the midfoot talocalcaneal angle > 40 (20-40 is normal)

Radiographic Evaluation
MRI considered for evaluation of the neural axis if an associated neuromuscular disorder is suspected

Differential Diagnosis
Oblique talus
reduces with forced plantar flexion

Calcaneovalgus foot deformity Tarsal coalition Paralytic pes valgus Pes planus valgus

Varied Deformity
Oblique talus talonavicular subluxation that reduces with forced plantarflexion of the foot treatment typically consists of observations and shoe inserts
some require surgical pinning of the talonavicular joint and achilles lengthening for persistent subluxatio

Conservative Care
preoperative serial manipulation and casting for three months
indications
indicated preoperatively to stretch the dorsal softtissue structures typically does not eliminate the need for surgery

technique
foot is held in plantarflexion and inversion

Surgical Correction
surgical release and talonavicular reduction and pinning indications
indicated in most cases performed at 6-12 months of age

technique
involves extensive release of talus with lengthening of contracted dorsolateral tendons (peroneals, Achilles, extensors) talonavicular joint is reduced and pinned while reconstruction of the plantar calcaneonavicular (spring) ligament is performed

Surgical Correction
minimally invasive correction
indications
new technique performed in some centers to avoid complications associated with extensive surgical releases

technique
principles for casting are similar to the Ponseti technique used clubfoot serial casting utilized to stretch contracted dorsal and lateral soft tissue structures and gradually reduced talonavicular joint once reduction is achieved with cast, closed or open reduction is performed and secured with pin fixation percutaneous achilles tenotomy is required to correct the equinus deformity

Surgical Option
talectomy indicated in resistent case

Pt outcomes and quality of life

Prognosis is good in treated cases poor in untreated cases and associated with significant disability